Question 1

The nurse is caring for a newborn with Erb palsy.The nurse understands that which reflex is absent with this condition?
A) Root reflex
B) Suck reflex
C) Grasp reflex
D) Moro reflex

Accepted Answer

Erb palsy (Erb-Duchenne paralysis)is caused by damage to the upper plexus and usually results from stretching or pulling away of the shoulder from the head.The Moro reflex is absent in a newborn with Erb palsy.The root and suck reflex are not affected.A grasp reflex is present in newborns because the finger and wrist movements remain normal.

Question 2

Rh hemolytic disease is suspected in a mother's second baby,a son.Which factor is important in understanding how this could develop?
A) The first child was a girl.
B) The first child was Rh positive.
C) Both parents have type O blood.
D) She was not immunized against hemolysis.

Accepted Answer

Hemolytic disease of the newborn results from an abnormally rapid rate of red blood cell (RBC)destruction.The major causes of this are maternal-fetal Rh and ABO incompatibility.If an Rh-negative mother has previously been exposed to Rh-positive blood through pregnancy or blood transfusion,antibodies to this blood group antigen may develop so that she is isoimmunized.With further exposure to Rh-positive blood,the maternal antibodies agglutinate with the RBCs of the fetus that has the antigen and destroy the cells.Hemolytic disease caused by ABO incompatibilities can be present with the first pregnancy.The gender of the first child is not a concern.Blood type is the important consideration.If both parents have type O blood,ABO incompatibility should not be a possibility.

Question 3

A mother brings her 6-week-old infant in with complaints of poor feeding,lethargy,fever,irritability,and a vesicular rash.What does the nurse suspect?
A) Impetigo
B) Candidiasis
C) Neonatal herpes
D) Congenital syphilis

Accepted Answer

Neonatal herpes is one of the most serious viral infections in newborns,with a mortality rate of up to 60% in infants with disseminated disease.Bullous impetigo is an infectious superficial skin condition most often caused by Staphylococcus aureus infection.It is characterized by bullous vesicular lesions on previously untraumatized skin.Candidiasis is characterized by white adherent patches on the tongue,palate,and inner aspects of the cheeks.Congenital syphilis has multisystem manifestations,including hepatosplenomegaly,lymphadenopathy,hemolytic anemia,and thrombocytopenia.

Question 4

A newborn has been diagnosed with brachial nerve paralysis.The nurse should assist the breastfeeding mother to use which hold or position during feeding?
A) Reclining
B) The cradle hold
C) The football hold
D) The cross-over hold

Accepted Answer

In brachial nerve paralysis,the affected arm is gently immobilized on the upper abdomen.Tucking the newborn under the arm (football hold)puts less pressure on the newborn's affected extremity.The other positions place the newborn's body next to the mother's and can cause pressure on the affected arm.

Question 5

A pregnant client asks the nurse to explain the meaning of "cephalopelvic disproportion." Which explanation should the nurse give to the client?
A) "It means a large for gestational age fetus."
B) "It is the narrow opening between the ischial spines."
C) "There is an uneven size between the fetus' presenting part and the pelvis."
D) "The shape of the pelvis is an android shape and is unfavorable for vaginal delivery."

Accepted Answer

Cephalopelvic disproportion means a disproportion (or uneven size)between the fetus' presenting part and the maternal pelvis.It does not mean a large for gestational age fetus or that the pelvis is an android shape.The narrow opening between the ischial spines is called the transverse measurement.

Question 6

A woman who is Rh-negative is pregnant with her first child,and her husband is Rh positive.During her 12-week prenatal visit,she tells the nurse that she has been told that this is dangerous.What should the nurse tell her?
A) That no treatment is necessary
B) That an exchange transfusion will be necessary at birth
C) That no treatment is available until the infant is born
D) That administration of Rh immunoglobulin is indicated at 26 to 28 weeks of gestation

Accepted Answer

The goal is to prevent isoimmunization.If the mother has not been previously exposed to the Rh-negative antigen,Rh immunoglobulin (RhIg)is administered at 26 to 28 weeks of gestation and again within 72 hours of birth.The intramuscular administration of RhIg has virtually eliminated hemolytic disease of the infant secondary to the Rh factor.Unless other problems coexist,the newborn will not require transfusions at birth.

Question 7

What is an important nursing intervention for a full-term infant receiving phototherapy?
A) Observing for signs of dehydration
B) Using sunscreen to protect the infant's skin
C) Keeping the infant diapered to collect frequent stools
D) Informing the mother why breastfeeding must be discontinued

Accepted Answer

Dehydration is a potential risk of phototherapy.The nurse monitors hydration status to be alert for the need for more frequent feedings and supplemental fluid administration.Lotions are not used; they may contribute to a "frying" effect.The infant should be placed nude under the lights and should be repositioned frequently to expose all body surfaces to the lights.Breastfeeding is encouraged.Intermittent phototherapy may be as effective as continuous therapy.The advantage to the mother and father of being able to hold their infant outweighs the concerns related to clearance.

Question 8

What should nursing care of an infant with oral candidiasis (thrush)include?
A) Avoid use of a pacifier.
B) Continue medication for the prescribed number of days.
C) Remove the characteristic white patches with a soft cloth.
D) Apply medication to the oral mucosa, being careful that none is ingested.

Accepted Answer

The medication must be continued for the prescribed number of days.To prevent relapse,therapy should continue for at least 2 days after the lesions disappear.Pacifiers can be used.The pacifier should be replaced with a new one or boiled for 20 minutes once daily.One of the characteristics of thrush is that the white patches cannot be removed.The medication is applied to the oral mucosa and then swallowed to treat Candida albicans infection in the gastrointestinal tract.

Question 9

Which is a bright red,rubbery nodule with a rough surface and a well-defined margin that may be present at birth?
A) Port-wine stain
B) Juvenile melanoma
C) Cavernous hemangioma
D) Strawberry hemangioma

Accepted Answer

Strawberry hemangiomas (or capillary hemangiomas)are benign cutaneous tumors that involve only capillaries.They are bright red,rubbery nodules with rough surfaces and well-defined margins.They may or may not be apparent at birth but enlarge during the first year of life and tend to resolve spontaneously by ages 2 to 3 years.A port-wine stain is a vascular stain that is a permanent lesion and is present at birth.Initially,it is a pink; red; or,rarely,purple stain of the skin that is flat at birth; it thickens,darkens,and proportionately enlarges as the infant grows.Melanoma is not differentiated into juvenile and adult forms.A cavernous hemangioma involves deeper vessels in the dermis and has a bluish red color and poorly defined margins.

Question 10

The parents of a newborn ask the nurse what caused the baby's facial nerve paralysis.The nurse's response is based on remembering that this is caused by what?
A) Birth injury
B) Genetic defect
C) Spinal cord injury
D) Inborn error of metabolism

Accepted Answer

Pressure on the facial nerve (cranial nerve VII)during delivery may result in injury to the nerve.Genetic defects,spinal cord injuries,and inborn errors of metabolism did not cause the facial nerve paralysis.The paralysis usually disappears in a few days but may take as long as several months.

Question 11

The nurse is planning care for an infant receiving calcium gluconate for treatment of hypocalcemia.Which route of administration should be used?
A) Oral
B) Intramuscular
C) Intravenous
D) Intraosseous

Accepted Answer

Calcium gluconate is administered intravenously over 10 to 30 minutes or as a continuous infusion.If it is given more rapidly than this,cardiac dysrhythmias and circulatory collapse may occur.Early feedings are indicated,but when the ionized calcium drops below 3.0 to 4.4 mg/dL,intravenous calcium gluconate is necessary.Intramuscular or intraosseous administration is not recommended.

Question 12

A mother is upset because her newborn has erythema toxicum neonatorum.The nurse should reassure her that this is what?
A) Easily treated
B) Benign and transient
C) Usually not contagious
D) Usually not disfiguring

Accepted Answer

Erythema toxicum neonatorum,or newborn rash,is a benign,self-limiting eruption of unknown cause that usually appears within the first 2 days of life.The rash usually lasts about 5 to 7 days.No treatment is indicated.Erythema toxicum neonatorum is not contagious.Successive crops of lesions heal without pigmentation.

Question 13

The nurse is caring for an infant who will be discharged on home phototherapy.What instructions should the nurse include in the discharge teaching to the parents?
A) Apply an oil-based lotion to the infant's skin two times per day to prevent the skin from drying out under the phototherapy light.
B) Keep the eye shields on the infant's eyes even when the phototherapy light is turned off.
C) Take the infant's temperature every 2 hours while the newborn is under the phototherapy light.
D) Make a follow-up visit with the health care provider within 2 or 3 days after your infant has been on phototherapy.

Accepted Answer

With short hospital stays,infants may be discharged with a prescription for home phototherapy.It is the responsibility of the nurse planning discharge to include important information such as the need for a follow-up visit with the health care provider in 2 or 3 days to evaluate feeding and elimination pattern and to have blood work done if needed.The parents should be taught to not apply oil or lotions to prevent increased tanning; the baby's eye shields can come off when the phototherapy lights are turned off,and the infant's temperature needs to be monitored but not taken every 2 hours.

Question 14

When should the nurse expect jaundice to be present in a full-term infant with hemolytic disease?
A) At birth
B) Within 24 hours after birth
C) 25 to 48 hours after birth
D) 49 to 72 hours after birth

Accepted Answer

In hemolytic disease of the infant,jaundice is usually evident within the first 24 hours of life.Infants with hemolytic disease are usually not jaundiced at birth,although some degree of hepatosplenomegaly,pallor,and hypovolemic shock may occur when the most severe form,hydrops fetalis,is present.Twenty-five to 72 hours after birth is too late for hemolytic disease of the infant.Jaundice at these ages is most likely caused by physiologic or early-onset breastfeeding jaundice.

Question 15

When should the nurse expect breastfeeding-associated jaundice to first appear in a normal infant?
A) 2 to 12 hours
B) 12 to 24 hours
C) 2 to 4 days
D) After the fifth day

Accepted Answer

Breastfeeding-associated jaundice is caused by decreased milk intake related to decreased caloric and fluid intake by the infant before the mother's milk is well established.Fasting is associated with decreased hepatic clearance of bilirubin.Zero to 24 hours is too soon; jaundice within the first 24 hours is associated with hemolytic disease of the newborn.After the fifth day is too late.Jaundice associated with breastfeeding begins earlier because of decreased breast milk intake.

Question 16

Which term is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery?
A) Hydrocephalus
B) Cephalhematoma
C) Caput succedaneum
D) Subdural hematoma

Accepted Answer

Caput succedaneum is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery.The swelling consists of serum or blood (or both)accumulated in the tissues above the bone,and it may extend beyond the bone margin.Hydrocephalus is caused by an imbalance in production and absorption of cerebrospinal fluid.When production exceeds absorption,fluid accumulates within the ventricular system,causing dilation of the ventricles.A cephalhematoma has sharply demarcated boundaries that do not extend beyond the limits of the (bone)suture line.A subdural hematoma is located between the dura and the cerebrum.It should not be visible on the scalp.

Question 17

The nurse is caring for a breastfed full-term infant who was born after an uneventful pregnancy and delivery.The infant's blood glucose level is 36 mg/dL.Which action should the nurse implement?
A) Bring the infant to the mother and initiate breastfeeding.
B) Place a nasogastric tube and administer 5% dextrose water.
C) Start a peripheral intravenous line and administer 10% dextrose.
D) Monitor the infant in the nursery and obtain a blood glucose level in 4 hours.

Accepted Answer

A full-term infant born after an uncomplicated pregnancy and delivery who is borderline hypoglycemic,as indicated by a blood glucose level of 36 mg/dL,and who is clinically asymptomatic should probably reestablish normoglycemia with early institution of breast or bottle feeding.The newborn does not require a nasogastric tube and 5% dextrose water or a peripheral intravenous line with 10% dextrose because the blood glucose level is only borderline.The infant does need to be monitored,but breastfeeding should be started and the blood glucose level checked in 1 to 2 hours.

Question 18

Which finding on a newborn assessment should the nurse recognize as suggestive of a clavicle fracture?
A) Positive scarf sign
B) Asymmetric Moro reflex
C) Swelling of fingers on affected side
D) Paralysis of affected extremity and muscles

Accepted Answer

A newborn with a broken clavicle may have no signs.The Moro reflex,which results in sudden extension and abduction of the extremities followed by flexion and adduction of the extremities,will most likely be asymmetric.The scarf sign that is used to determine gestational age should not be performed if a broken clavicle is suspected.Swelling of the fingers on the affected side and paralysis of the affected extremity and muscles are not signs of a fractured clavicle.

Question 19

Which intervention may decrease the incidence of physiologic jaundice in a healthy full-term infant?
A) Institute early and frequent feedings.
B) Bathe newborn when the axillary temperature is 36.3° C (97.5° F).
C) Place the newborn's crib near a window for exposure to sunlight.
D) Suggest that the mother initiate breastfeeding when the danger of jaundice has passed.

Accepted Answer

Physiologic jaundice is caused by the immature hepatic function of the newborn's liver coupled with the increased load from red blood cell hemolysis.The excess bilirubin from the destroyed red blood cells cannot be excreted from the body.Feeding stimulates peristalsis and produces more rapid passage of meconium.Bathing does not affect physiologic jaundice.Placing the newborn's crib near a window for exposure to sunlight is not a treatment of physiologic jaundice.Colostrum is a natural cathartic that facilitates meconium excavation.

Question 20

What is an infant with severe jaundice at risk for developing?
A) Encephalopathy
B) Bullous impetigo
C) Respiratory distress
D) Blood incompatibility

Accepted Answer

Unconjugated bilirubin,which can cross the blood-brain barrier,is highly toxic to neurons.An infant with severe jaundice is at risk for developing kernicterus or bilirubin encephalopathy.Bullous impetigo is a highly infectious bacterial infection of the skin.It has no relation to severe jaundice.A blood incompatibility may be the causative factor for the severe jaundice.

Quiz 8: Health Problems of Newborns

The nurse is caring for a newborn with Erb palsy.The nurse understands that which reflex is absent with this condition?

Rh hemolytic disease is suspected in a mother's second baby,a son.Which factor is important in understanding how this could develop?

A mother brings her 6-week-old infant in with complaints of poor feeding,lethargy,fever,irritability,and a vesicular rash.What does the nurse suspect?

A newborn has been diagnosed with brachial nerve paralysis.The nurse should assist the breastfeeding mother to use which hold or position during feeding?

A pregnant client asks the nurse to explain the meaning of "cephalopelvic disproportion." Which explanation should the nurse give to the client?

A woman who is Rh-negative is pregnant with her first child,and her husband is Rh positive.During her 12-week prenatal visit,she tells the nurse that she has been told that this is dangerous.What should the nurse tell her?

What is an important nursing intervention for a full-term infant receiving phototherapy?

What should nursing care of an infant with oral candidiasis (thrush) include?

Which is a bright red,rubbery nodule with a rough surface and a well-defined margin that may be present at birth?

The parents of a newborn ask the nurse what caused the baby's facial nerve paralysis.The nurse's response is based on remembering that this is caused by what?

The nurse is planning care for an infant receiving calcium gluconate for treatment of hypocalcemia.Which route of administration should be used?

A mother is upset because her newborn has erythema toxicum neonatorum.The nurse should reassure her that this is what?

The nurse is caring for an infant who will be discharged on home phototherapy.What instructions should the nurse include in the discharge teaching to the parents?

When should the nurse expect jaundice to be present in a full-term infant with hemolytic disease?

When should the nurse expect breastfeeding-associated jaundice to first appear in a normal infant?

Which term is defined as a vaguely outlined area of edematous tissue situated over the portion of the scalp that presents in a vertex delivery?

The nurse is caring for a breastfed full-term infant who was born after an uneventful pregnancy and delivery.The infant's blood glucose level is 36 mg/dL.Which action should the nurse implement?

Which finding on a newborn assessment should the nurse recognize as suggestive of a clavicle fracture?

Which intervention may decrease the incidence of physiologic jaundice in a healthy full-term infant?

What is an infant with severe jaundice at risk for developing?